Provider Demographics
NPI:1104306620
Name:BULLOCK, CONSTANCE R (FNP-C)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:R
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 S US HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-8142
Mailing Address - Country:US
Mailing Address - Phone:317-418-5819
Mailing Address - Fax:
Practice Address - Street 1:6440 W 34TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-1138
Practice Address - Country:US
Practice Address - Phone:317-293-4930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMB4968143363LF0000X
INF07180086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily